When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?
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Solution
Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
Option A: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels.
Option B: Oxygenation is evaluated through Pao2 and oxygen saturation.
Option D: Alveolar hypoventilation would be reflected in an increased Paco2.
Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?
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Solution
Narcotics are avoided after a head injury because they may hide a worsening condition.
Option C: Narcotics may mask changes in the level of consciousness that indicate increased ICP.
Option A: Acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate.
Option B: Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome.
Option D: Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:
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Solution
Pancytopenia, elevated antinuclear antibody (ANA) titer
Option C: Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels.
Option D: Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.
Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:
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Solution
It inhibits reabsorption of sodium and water in the loop of Henle.
Option D: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure.
Option A: Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure.
Option B: Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure.
Option C: Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?
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Solution
Kidneys’ excretion of sodium and water
Option C: The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic blood pressure by regulating blood volume.
Option B: Sodium or water retention would only further increase blood pressure.
Option D: Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.
The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:
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Solution
Cardiogenic shock
Option B: Cardiogenic shock is shock related to ineffective pumping of the heart.
Option A: Anaphylactic shock results from an allergic reaction.
Option C: Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output.
Option D: MI isn’t a shock state, though a severe MI can lead to shock.
Which of the following treatment is a suitable surgical intervention for a client with unstable angina?
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Solution
Percutaneous transluminal coronary angioplasty (PTCA)
Option D: PTCA can alleviate the blockage and restore blood flow and oxygenation.
Option B: An echocardiogram is a noninvasive diagnosis test.
Option C: Nitroglycerin is an oral sublingual medication.
Option A: Cardiac catheterization is a diagnostic tool – not a treatment.
After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?
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Solution
Apply gloves and assess the groin site
Option D: Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding.
Option A: The nurse would call for help if it were warranted after the assessment of the situation.
Option B: After determining the extent of the bleeding, vital signs assessment is important.
Option C: The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.
Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?
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Solution
Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
Option B: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.
When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactulose p.o. every 2 hours. Mr. Gonzales develops diarrhea. The nurse best action would be:
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Solution
“I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
Option C: Lactulose is given to a patient with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates overdosage and the nurse must reduce the amount of medication given to the patient. The stool will be mushy or soft. Lactulose is also very sweet and may cause cramping and bloating.